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COVID-19 Questionaire
Please fill all of this information, prior to your scheduled appointment
* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Your Name
*
Your answer
Email
*
Your answer
Phone number
*
Your answer
Do you have new or worsening onset of any of the following symptoms: fever, cough, shortness of breath, runny nose, sore throat, chills, body aches, fatigue, headache, loss of taste/smell, eye drainage, congestion?
*
Yes
No
Other:
In the last 14 days have you traveled outside your normal, daily routine?
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Yes
No
Other:
Have you been exposed to someone being tested for COVID-19 or who has symptoms compatible with COVID-19?
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Yes
No
Other:
Are any members of your household a close contact on quarantine for exposure to COVID-19?
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Yes
No
Other:
In the past 2 weeks, have you (or someone in your household) been diagnosed, tested, or quarantined under a doctor's orders fro COVID-19?
*
None of the below
Dr. Ordered me to quarantine for possible COVID-19
I was tested and am waiting for results
I tested positive
I tested negative
Other:
Required
A copy of your responses will be emailed to the address you provided.
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